Cognitive Restructuring

These last months I've devoted essays to a survey of important technical contributions to psychotherapy made by the various important psychotherapy schools. Thus far we've covered psychodynamic and early behavioral school technical contributions. We have two more schools to go (Family Systems and the Humanists).

Today's essay covers the second important technical contribution of the behavioral school to modern psychotherapy, namely the "analysis of appraisal" that takes place within cognitive reframing or restructuring exercises characteristic of the cognitive behavioral school. Before we talk about how this technique works, we should first talk about how the cognitive school came to expand the vision and potential of the behavioral school over the last thirty years.

You'll recall that psychodynamic psychotherapists spent the later years of the 19th century and the early years of the 20th century creating beautiful mental theories of the mind, filled with interesting and important concepts like the division of the mind into ego, id, and super-ego components, the idea of repression and the identification of transference as an important process shaping people's relationships. I've devoted a few essays to these topics, and if you want to read about them, they're in the essay archives at Mental Help Net. Psychodynamic therapists applied their theories in their work with patients, pushing those patients towards greater insight regarding their problems. Many people who encountered these beautiful psychodynamic theories were pretty much impressed with them. However, there are always critics, and sometimes those critics have something meaningful to say.

The most important early critics of the psychodynamic enterprise were the behaviorists, who were by and large academic psychologists working very hard to make a science out of psychology. When the behaviorists looked upon the psychodynamic theories, they saw the beautiful systems of thought that everyone else did, but they also saw that those systems of thought were free-floating and not based solidly on a foundation of systematic scientific observation. They saw no attempts to provide evidence that things like the ego or id actually existed or that knowing about repressed thoughts or memories would prove curative for patients. They saw no rigorous studies at all; only the words of charismatic therapists and their case studies and testimonials were there to support the theories. Most people were willing to overlook this important point, but the behaviorists couldn't do that, being scientists by training. They saw a beautiful mansion built on a swamp of a foundation and there was no way they were going to invest money or attention in such a questionable structure.

Wanting nothing to do with a non-scientific psychology, the behaviorists decided they would build their own theories and psychotherapy practices, but this time on a foundation that was unquestionably solid; that of learning theory. And build they did. Between about 1930 and 1970, the scientific study of animal and human learning was continuously refined with countless psychological research studies, and a refined behavioral psychotherapy based on principles of learning theory was offered to patients suffering from a variety of issues. Last month's essay ("Learning theory") describes some of the behavioral approaches to therapy, notably systematic desensitization and exposure with response prevention. It too is in the essay archives if you want to read about these techniques.

The Behaviorist Mistake

The early behaviorists were way too gung-ho in their embrace of learning theory, as it turns out. In their zeal to build a psychotherapy on exclusively empirical (scientific) and provable grounds, they restricted themselves to talking about only what they could easily measure: stimulus events (events that provoke a response) and responses (which are behavioral reactions to stimulus events). They refused to talk about anything else, or even to acknowledge that other things could be important. Because the early behaviorists were only interested in stimulus and response, the psychology they built came to be described as an "SR" approach.

The SR mindset lead behaviorists to construct a psychology and a psychotherapy that refused to talk about mental events like thoughts and emotions and important ideas like consciousness, willpower, and mind. In the early behaviorist way of seeing things, what someone thought or felt about a given stimulus was irrelevant. What was important was what he or she did in response to that stimulus. The subjective insides of human beings were considered to be an unimportant place. Through the lens of early behaviorism, people were mere behaving objects indistinguishable from animals except with regards to the sophistication of the behaviors they were capable of producing.

While the behaviorist SR perspective did result in a solid set of useful psychotherapy techniques, it produced a view of the person that was entirely objective in nature, and thus cold and disinterested in the subjective stuff that makes people uniquely human – their thoughts and feelings. The approach failed to recognize the essentially subjective nature of people – that they were thinking and feeling beings who made decisions and interpreted events they experienced. Early behaviorism had missed something important and therefore was itself in need of being rejected and rebuilt. Though criticism with regard to the rejection of mental events from behavioral psychotherapy had been offered from the approaches earliest days, the movement to integrate mental events into behaviorism began in earnest in the 1960 and 70s and rapidly gathered steam through the 1980s and 90s. Today, cognitive-behaviorism (which successfully integrates mental events into a behavioral framework) has become the dominant form of behavioral thought.

I should make clear here that the early behaviorists were not idiots. They knew quite well that people thought and felt and that these were important things. They knew they were conscious by the same indisputable logic that every person knows they are conscious (e.g., "I think therefore I am"). They knew that thinking and feeling were real; they just didn't want to deal with thinking and feeling in their approach to therapy because that would make their approach to therapy too messy and unpredictable. They wanted a clean, minimalist approach to therapy that would help them make clear predictions about how patients would behave given particular interventions – in the same manner that pool players want to develop a clean minimalist understanding of how billiard balls will roll when they are hit from particular angles. Imagine how much more difficult pool would be if the balls were conscious and made decisions about how they would roll each time you hit them, and you'll understand why the behaviorists resisted thinking about subjective experience. They did their best to keep thinking and feeling out of therapy, but ultimately, because these are important things – because people's thinking and feeling do influence how they "roll" - these mental things did find their way into behaviorism.

The Rise of Cognitivism

The 1960s and 70s saw the birth of cognitive behavioral therapies (sometimes today called simply "cognitive therapies"), first in the form of Albert Ellis's Rational Emotive Therapy (RET; later Rational Emotive Behavior Therapy or REBT) and later, Arron Beck's Cognitive Behavioral Therapy (CBT). These therapies are considered "cognitive" because they address mental events such as thinking and feeling. They are called "cognitive behavioral" because they address those mental events in the context of the learning theory that was the base for the old pure-behavioral therapy. In cognitive therapy the mind is taught new habits of thinking using the same old learning-theory-derived procedures that made systematic desensitization and other pure-behavioral interventions work.

Today, cognitive behavioral psychotherapy is pretty much the dominant psychotherapy approach in American psychotherapy, having achieved this position sometime between the 1980s and 1990s. The rise of the cognitive approach to psychotherapy has been based itself on changes in the health care system, most notably the rise of managed care approaches to health insurance. There is less money available to pay for therapy than in past years. Also, the importance of accountability has risen dramatically. In response, cognitive therapies have become manualized so that they can be administered by inexpensive kinds of therapists, and designed to produce an effect in a short amount of time, making them cost effective to offer relative to other forms of psychotherapy. More importantly, they have been extensively researched. Modern cognitive therapies qualify as "evidenced based medicine" in a way that traditional psychodynamic psychotherapy never could; we know they work in the same way we know that medications and surgeries work (e.g., because both forms of therapy have been extensively researched with actual patient groups and found to relieve symptoms). Truly, the architects of cognitive therapy understood where the health care culture was headed, and made their therapy a best fit for the times.

How Cognitive Therapy Works

Cognitive behavioral therapies are based on the premise that cognitive (mental) events are very important; that people actively interpret and appraise events that happen to them, even though they are not commonly aware that they are doing this. Their appraisal process – their process of making sense of stimulus events – essentially determines how they will react to those stimulus events. In other words, people do not passively response to events in predetermined ways, but rather add their own 'spin' to events which helps to determine how they will ultimately respond to those events. Cognitive behavioral therapies are sometimes referred to as "SOR" approaches, with the "O" standing for organism in recognition that there is a thinking person who interprets the meaning of stimulus events (the "S"), before acting out a response.

According to cognitive behavioral theory, cognitive (thoughtful) appraisal drives emotional responding. What you think about what is happening to you influences how sad or worried you will feel in response, even when you are not especially aware of having interpreted those events. Problematic mood disorders involving anxiety and depression can occur when people's appraisal processes get messed up and they come to the wrong conclusions about the meaning of various stimulus events they are confronted with. The way to fix such problem moods is thus to help the people experiencing those problem moods to become better, more accurate appraisers.

The basic technique that is taught in cognitive behavioral psychotherapy is something that could be called the "Analysis of Appraisal", although it is usually called "cognitive restructuring" or sometimes "cognitive reframing" instead. In essence, cognitive therapists teach their patients to become conscious of the fact that they are unconsciously appraising and judging all the various stimulus events that come their way, and then teach them to consciously take charge of that appraisal process so as to make sure that their conclusions are accurate and free of biases and mistakes.

Thinking Influences Behavior

An example will help make this brief and fairly abstract description of cognitive therapy more understandable. Let's say that you're depressed, and as part of your treatment for depression you visit a cognitive behavioral psychotherapist. After orienting you, answering questions and getting you comfortable, the therapist is going to provide an explanation of how it is that depression occurs which will go something like this:

"People think that depression just occurs randomly, but it really isn't like that most of the time. Usually, depression occurs in response to certain depressing events. Are events themselves actually depressing, though? No; Events themselves are neutral. It is our interpretation of those events that makes them take on depressing, or uplifting qualities."

The point of this explanation is to teach this basic and all important sequence: that events which occur, trigger an appraisal process which interprets the meaning of those events, resulting in a behavioral consequence, which could be depression, or any number of other outcomes. Schematically, the sequence is sometimes taught as "ABC", where "A" stands for activating events, "B" stands for beliefs (which drive interpretation and appraisal), and "C", standing for consequences.

Teaching the sequence involved in how a depressed mood occurs is important for several reasons. It sets the stage for what occurs next, which is a set of interventions designed to help patients identify and alter their interpretation process. It is also empowering in of itself, because it may be the first time that a patient has considered that he or she can have control over how he or she feels.

Core Beliefs and Cognitive Biases

After teaching the sequence of events behind the onset of depressed feelings, the therapist will introduce other important concepts, such as Core Beliefs, Cognitive Biases, and Automatic Thoughts. The reason that one person gets depressed when faced with a given event, while another person shrugs it off has to do with how those two people interpret the meaning of the event. Each person has a different set of core beliefs about themselves, their relationships and their world, and these different core beliefs act like filters, causing them to draw different conclusions about the meaning of an event that has occurred. The depressed person's beliefs are negatively biased (loaded, weighted, bent, etc.) in such a way as to all but insure that most any event that occurs will be further cause for depression. Conversely, the non-depressed person's belief set is either not biased very much, or biased in a more positive direction, so that events will invariably be seen in a positive light; a quality generally described as optimism. "The process of interpreting the meaning of events happens very quickly", the therapist will tell you, "and you may very well not be all that aware that you are interpreting events at all".

Core beliefs are invisible sorts of things whose existence and shape can only be pieced together by paying attention to the thoughts that naturally and spontaneously flow through each person's mind. Such thoughts are often referred to as "Automatic Thoughts" to reflect their continuous, unbidden quality. A depressed person's automatic thoughts contain the stamp of their negatively biased core beliefs. They will spontaneously conclude, "I'm a loser, I never had a chance at that job in the first place", when faced with a rejection letter because they deeply believe at some level that they are not worthy and not capable of influencing their circumstances. Non-depressed people's automatic thoughts would reflect their own neutral or positive biases. "There is a lot of competition out there for jobs, but I will ultimately find one if I keep at it", they might conclude, because their core beliefs support a self view as worthy, and as capable of positively influencing their lives for the better through hard work.

"If the difference between depressed and non-depressed responses to life events reduces to the presence or absence of depressing core-beliefs and automatic thoughts, then the best way for a depressed person to learn to feel better is to learn how to think more like a non-depressed person does", your therapist might say. What he has in mind for you, however, is not a simple "put on a happy face" sort of thought substitution exercise. Superficial fixes won't work, because they won't touch you where you live, in the core beliefs that cause you to develop biased conclusions in the first place. Instead, your therapist is proposing to teach you how to carefully examine and critique your automatic thoughts and core beliefs themselves so as to root out the source of bias that cause you to interpret things negatively. You will root out the negative bias by identifying and rejecting automatic thoughts that you know are biased, and by attempting to replace them with more honest and objectively accurate thoughts. With repeated practice doing this, the exercise will become a habit, and the core beliefs will start to shift so as to become less biased. As the negative bias is rooted out, you will naturally begin to feel better, because you will perceive fewer circumstances that merit being depressed about.

Common Cognitive Biases

Your therapist will then proceed to teach you about the common ways that core beliefs and the automatic thoughts that spring from them can be biased. Here are a few examples, drawn from a much larger list of biases that creative people have invented for themselves:

Overgeneralization is a common cognitive bias that causes people to mistakenly conclude that things are worse than they really are. Overgeneralization occurs when a person takes something that is true for one domain of life and applies it to another domain of life where it doesn't fit. "I failed to get a second interview", says the overgeneralizing depressed person, "so that must mean that I am a failure as a person".

Selective Attention is another sort of common cognitive bias or error that many people make. In selective attention, a depressed person pays attention to one or two bits of bad news contained within a complex message that also contains many bits of positive news. "Our vacation is ruined because of this rain!" says the depressed person, failing to pay attention to the fact that he is on vacation in the first place. "I got a C in that subject on the report card and that is terrible" says the depressed person, failing to give proper credence to the fact that As and Bs have been earned in other subjects.

Catastrophization is yet another form of cognitive bias. In catastrophization a small negative event which in reality is merely inconvenient or uncomfortable is magnified into something "terrible, awful, and unbearable".

Cognitive errors like these are fairly easy to identify and correct when they're written down on paper, but they are quite difficult to spot in the wild, as they flit through your head automatically without your even noticing them. The trick to cognitive therapy then is to take the time to write down the thoughts that occur to you in the wake of a troubling event, and then to examine those thought records for the presence of cognitive errors.

The Thought Record and Cognitive Restructuring

If he hasn't done so already, your therapist will now give you a paper form called a thought record, which is a tool for recording your automatic thoughts and fixing them when you know they are biased. The thought record is commonly broken into columns. In the first column, you write down something depressing that has happened (e.g., the Activating Event). In the second column, you write down verbatim some of the thoughts that are flying through your head while you think about the activating event. In the third column, you record how you are feeling as a result of those thoughts in the second column. In the fourth column you can identify what sorts of cognitive errors are present in your (second column) thoughts. In the fifth column, you can write down a "fixed" version of your (second column) thoughts with the biases you identified in the fourth column all stripped out. Finally, in a sixth column, you can record how you feel after contemplating the fixed thoughts from column five.

This exercise, often called cognitive reframing or restructuring, is the very heart of cognitive behavioral therapy. Repetitive practice with this exercise trains you to become aware of and reject cognitive errors that creep into your thoughts, causing you to become depressed. As you learn to make fewer cognitive errors, you will naturally start to feel better. Though simple in structure, the thought record exercise can be tricky to actually implement. People have a hard time learning to identify their automatic thoughts in the first place, or to know what cognitive errors they may be making, or how to rewrite their thoughts with the biases removed. The exercise is difficult precisely because people are very embedded in their unconsciously biased mode of interpreting events and have difficultly gaining the perspective on their own thought process necessary to see the automatic thoughts happening there in the background of the mind. The therapists' main purpose, in cognitive therapy, is thus to help you (the patient) gain the perspective and practice you need in order to get good at the thought record restructuring task. It takes most people a few months of regular practice, complete with homework consisting of filling out thought record after thought record, and consideration of depressing event after depressing event, to gain these skills. At the end of the process, however, you have gained the ability to see (perhaps for the first time) how your own mind creates your emotional experience, and you have gained the tools necessary to influence your thought process for the better.

So – that is cognitive therapy in a nutshell. The therapy empowers people to grab hold of their own thought process and fix the mental mistakes they make that lead them to make themselves depressed. We should mention that this therapy is useful far beyond just helping people overcome depression. It has also been shown to be helpful for helping people overcome anxiety disorders (including obsessive compulsive disorder, panic disorder, and phobias), substance abuse issues, and even (as a secondary treatment, after medical assistance has been rendered) psychotic disorders (including schizophrenia and bipolar disorder) when patients are high functioning.

With regards to depression, studies have shown that cognitive therapy is often as effective a treatment for depression as anti-depressant medication. What's more, its anti-depressant effect lasts longer than medication's anti-depressant effect when both therapies are stopped. This is probably because anti-depressant medications act directly on the brain's structure and chemistry to suppress the likely that depressive interpretations will be made, while cognitive therapy teaches you how to avoid taking seriously the depressive interpretations that otherwise do get made. When anti-depressant medications are no longer taken, the brain tends to go back to its pre-drug structure and chemistry, making it more likely that depressive interpretations will become common again. No such suppressive-rebound will occur in the wake of cognitive therapy, because nothing was ever suppressed.

Though cognitive therapy's focus on mental events would have been considered heretical by the early behaviorists, the therapy has remained true to its behavioral roots. It is, I think, quite durably here to stay (although it will certainly continue to evolve) for simple solid reasons: scientific studies show it works, it is short term in duration, it is focused, it offers accountability, and it is cheap to implement relative to other forms of psychotherapy. Cognitive therapy fits our health care culture's needs like no other current therapy. It will likely take a cultural shift before some other therapy rises to take its current dominant place.